Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213ES0103X | Foot & Ankle Surgery | 016005776 | IL |
Y | 213ES0103X | Foot & Ankle Surgery | 07001318A | IN |
N | 213ES0103X | Foot & Ankle Surgery | 111825 | WI |
NPI | 1043606247 |
---|---|
Provider Name | Dr. Nathan Shane |
First Address | Fort Wayne, IN 46825-5886 |
Second Address | Fort Wayne, IN 46825-5886 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2015 |
Last Update Date | 24/05/2021 |